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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3256_Библиотеки_им_академика_М_И_Перельмана
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361
of the skin, an enlarged liver, sent the patient to an infectious diseases
hospital for specialist advice.
On objective examination: the patient’s condition is severe, signif-
icant pallor and moderate icterus of the skin and mucous membranes,
pronounced puness of the face, edema of the legs. Consciousness
is clear, speech is slowed down. The lymph nodes are not enlarged.
There is a small amount of wet rales in the lower parts of the lungs.
The heart is enlarged by 2 cm to the left of the left midclavicular line.
Mued heart sounds, systolic murmur over all points. Pulse - 109
in 1 min, rhythm is regular. BP - 90/60 mm Hg. Art. The tongue is
bright red, smooth, with cracks. The liver protrudes 4 cm from the
edge of the costal arch, sensitive to palpation. The edge of the spleen
is palpated. Neurological status: distal hyperesthesia, increased deep
tendon reexes, decreased muscle strength of the lower extremities.
ECG data: sinus rhythm, right bundle branch block. Negative
T wave in V4-V6 leads.
Complete Blood Count: RBC – 1,0х10
12
/L, Нb –40 g/L, WBC –
3,6х10
9
/L, neutrophils bands – 5%, neutrophils segments – 48%, lym-
phocytes – 31%, monocytes – 4%, eosinophil – 2%, PLT – 150,0х10
9
/L,
anisocytosis (macrocytosis), poikilocytosis, megalocytes, Jolly bodies
, Cabot’s rings. ESR – 23 mm/h.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 6
Patient N, 68 years old, a manager, went to the polyclinic for an
appointment with a family doctor with complaints of general weak-
ness, lethargy, palpitations, shortness of breath on exertion, nausea,
belching, heaviness and discomfort in the epigastric region. Signs of
t.me/medicina_free
362
gastric dyspepsia for about 13 years, was treated with folk methods,
herbs, did not go to doctors. In the last six months, weakness, palpi-
tations, lack of air during exertion, numbness of the lower extremi-
ties appeared.
On objective examination: general condition of moderate sever-
ity. The skin is pale, slight yellowness of the skin and lemon-colored
sclera. The face is puy. Height - 160 cm, body weight - 68 kg. Ve-
sicular respiration in the lungs. The borders of the heart are displaced
to the left by 1 cm, the tones are slightly mued, heart rate - 90 per
minute, blood pressure - 130/80 mm Hg. Art. The tongue is crimson,
the papillae are smoothed. The abdomen is soft and painless. The liver
protrudes 1 cm from under the costal margin, the spleen is not en-
larged.
Complete Blood Count: RBC – 2,9х10
12
/L, Нb –75 g/L,
WBC – 6,0х10
9
/L, neutrophils bands – 2%, neutrophils segments –
67%, lymphocytes – 20%, monocytes – 8%, eosinophil – 1%, PLT –
214,0х10
9
/L, Jolly’s bodies and Kebot’s rings, ESR – 30 mm/h.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 7
Patient N, 37 years old, a city farmer, at the reception with a fam-
ily doctor complains of weakness, dizziness, the appearance for no
apparent reason of nose and gingival bleeding, bruises on the skin
of the extremities, up to 1.5 cm in size. Considers himself sick for
5 months, after the patient went to the lake in the mountains. However,
upon careful questioning, it was found out that 3-4 months ago she had
a severe viral infection.
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363
On objective examination. When contacting the clinic, a state of
moderate severity. Severe pallor of the skin and mucous membranes.
On the skin of the legs, ecchymosis up to 1, 5 - 2 cm in diameter
was found, as well as petechial eruptions of varying degrees of matu-
rity. When examining the oral cavity - petechial rashes on the mucous
membrane of the tongue, cheeks. The tonsils are not enlarged. The
circulatory system - the boundaries of the relative dullness of the heart
are shifted to the left. On auscultation -1 tone at the apex is weakened,
systolic murmur is heard not associated with I tone, without a conduc-
tion beam. Heart rate - 96 beats per minute. BP - 80/60 mm Hg. Art.
On the part of the respiratory system, gastrointestinal tract, urinary
system without features. The liver and spleen were not palpable.
Complete Blood Count: RBC – 1,4х10
12
/L, Нb –54 g/L, MCH –
27 pg/cell, WBC – 2,1х10
9
/L, neutrophils bands – 2%, neutrophils
segments – 35%, lymphocytes – 55%, monocytes – 9%, reticulocytes
- 20%, eosinophil – 1%, PLT – 22,0х10
9
/L, ESR – 42 mm/h.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 8
Patient N, 29 years old, a ight attendant, complains to a family
doctor in a polyclinic about general weakness, dizziness, shortness of
breath, brittle nails, ashing of ies before her eyes, desire to eat earth,
clay, sand. From the anamnesis it is known that there is a chronic dis-
ease: duodenal ulcer from the age of 15. Menses for 7 days, profuse,
painful on the rst day. Heredity is not burdened. Married, pregnan-
cies, childbirth was not.
On objective examination, the skin and mucous membranes are
pale. The boundaries of the heart are not displaced, the tones are
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364
mued. In the lungs, vesicular breathing, no wheezing. The liver and
spleen are not enlarged.
Complete Blood Count: RBC – 2,6х10
12
/L, Нb –60 g/L, MCH –
17 pg/cell, WBC – 5,1х10
9
/L, neutrophils bands – 5%, neutrophils
segments – 57%, lymphocytes – 28%, monocytes – 8%, eosinophil –
2%, PLT – 210,0х10
9
/L, ESR – 15 mm/h. Serum iron - 6 μmol.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 9
Patient N, 27 years old, a trend watcher, complained of severe
weakness, fever up to 38.3 ° C, dizziness. He considers himself sick
from a shing trip, which was two weeks ago, where, according to
the words, he could be hypothermic. 8 days ago I turned to my family
doctor, where I was diagnosed with acute pharyngitis. However, the
condition continued to deteriorate despite the ongoing therapy.
On objective examination: the patient’s condition is moderate.
the skin and mucous membranes are pale, the submandibular cervical
lymph nodes are enlarged, painless. In the lungs, vesicular breathing,
no wheezing. The heart sounds are mued, the rhythm is correct. The
abdomen is soft and painless. The liver is palpable at the edge of the
costal arch, the spleen protrudes 2 cm, painless.
Complete Blood Count: RBC – 2,5х10
12
/L, Нb –79 g/L,
WBC – 6,1х10
9
/L, neutrophils bands – 5%, neutrophils segments –
67%, lymphocytes – 10%, monocytes – 8%, eosinophil – 1%, PLT –
100,0х10
9
/L, blasts-85%, ESR – 11 mm/h.
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365
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 10
Patient N, 23 years old, a guide, complains of lethargy, dizziness
with a sudden change in position, increased fatigue, bouts of severe
pain in the right hypochondrium, especially during intense physi-
cal exertion. From the anamnesis it is known that from the age of 10
the patient notes intermittent yellowness of the skin, alternating with
pallor, while the attacks were accompanied by severe weakness. In
the last 5 years, the patient began to worry about paroxysmal pain
in the right hypochondrium, accompanied by jaundice. Smokes since
17 years.
On objective examination: satisfactory condition, clear con-
sciousness. The skin and visible mucous membranes are icteric against
a generally pale background, the sclera are icteric. Peripheral lymph
nodes are not enlarged. In the lungs, breathing is carried out over
all elds, there are no wheezing. NPV - 17 per min. Rhythmic heart
sounds, a blowing systolic murmur is heard at the apex of the heart.
Heart rate - 84 beats per minute. The liver on palpation is of a normal
consistency, painful, the edge is rounded, protrudes 2.5 cm from under
the edge of the costal arch. Dimensions according to Kurlov - 12 ×
10 × 9 cm. The spleen protrudes 3 cm below the left costal arch. On
supercial palpation, the abdomen is soft, painless.
Complete Blood Count: RBC – 3,2х10
12
/L, Нb –92 g/L, MCH –
22 pg/cell, WBC – 12х10
9
/L, neutrophils bands – 11%, neutrophils
segments – 59%, lymphocytes – 30%, monocytes – 10%, eosinophil –
1%, PLT – 214,0х10
9
/L, ESR – 20 mm/h.
Osmotic resistance of erythrocytes (ORE) - 0.78-0.56% (normal
minimum ORE - 0.44-0.48%, max. ORE - 0.28-0.36%). Biochemical
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blood test: bilirubin - 111.2 μmol / L, direct - 17.1 μmol / L, indirect -
94.1 μmol / L. Coombs’ test is negative.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
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Chapter 14. STANDARD OF ANSWERS
FOR THE HEMATOLOGY SECTION
Clinical case No. 1
1. What is the preliminary diagnosis?
Acute leukemia, debut. Hepatosplenomegaly. Moderate anemia.
Thrombocytopenia. Hemorrhagic syndrome.
The diagnosis of acute leukemia was made on the basis of clinical
data: hepatosplenomegaly, hemorrhagic, anemic syndromes, intoxica-
tion. The main diagnostic criteria are laboratory data: in the general
blood test - leukocytosis (less often leukopenia), the presence of blast
cells, a symptom of leukemic “failure”, anemia (hemoglobin - 78 g /
l corresponds to moderate severity) and thrombocytopenia. The main
studies to clarify the diagnosis are: complete blood count (leukocyto-
sis, presence of blasts, leukemic “failure”, anemia, thrombocytope-
nia); sternal puncture (20% or more blast cells in the myelogram); cy-
tochemical study and immunophenotyping of blasts (determination of
the variant of leukemia), cytogenetic study of the bone marrow (deter-
mination of prognostically favorable and / or unfavorable cytogenetic
defects); diagnostic lumbar puncture (to exclude neuroleukemia); Ul-
trasound of internal organs (in order to clarify the degree of leukemic
inltration of the liver and spleen).
2. What additional tests would you recommend to the patient,
and what are the expected results?
¾ The bone marrow is punctured with a needle inserted into the
bone cavity. Usually the chest is selected for biopsy. The study shows
the presence of an acute or chronic process. The analysis can determine
the cytogenetic and morphological type of the disease. This procedure
checks the response of the aected cell to the chemotherapy drug.
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¾ A myelogram reveals the ratio of abnormal cells to normal
cells. The examination shows the degree of damage to the organism.
In a healthy person, blast cells should not exceed 5%. The test material
is represented by a bone marrow sample. During the procedure,
lymphocytosis and the nature of atypical cells are detected. There are
no megakaryocytes. This method is recognized as the most accurate
for making a diagnosis.
¾ Cytochemical laboratory diagnostics is based on the
determination of specic enzymes. The method is indispensable for
determining acute forms of the disease and predicting their course.
¾ Immunophenotyping is performed to diagnose acute
lymphocytic and myeloid leukemia. The tactics of treatment of these
types of leukemia are dierent, so it is important to clarify the diagnosis.
¾ It is necessary to examine the cerebrospinal uid (cerebrospinal
uid) to detect an increased number of cells (cytosis).
Instrumental methods. With the help of computed tomography,
vascular damage and metastases in the lymph nodes are detected. The
method is used for large-scale diagnostics of the body by means of
layer-by-layer scanning. Chest X-ray is prescribed for characteristic
symptoms of lung damage: regular coughing, sputum production with
blood inclusions, chest pain. If the oncological process has aected
the brain, magnetic resonance imaging is recommended. The disease
is characterized by symptoms: blurred vision, numbness of the limbs,
impaired memory and consciousness, dizziness and fainting. To detect
abnormalities in the work of the heart muscle, an electrocardiogram
and an echocardiogram are performed.
3. What is the patient’s management?
To verify the diagnosis and treatment, hospitalization in the hema-
tology department is indicated. Treatment includes cytostatic therapy:
polychemotherapy is used according to standard programs, depending
on the type of leukemia. The stages of treatment include: induction of
remission, consolidation, maintenance therapy, prevention of neuro-
gliomata. In acute lymphoblastic leukemia, Holzer’s 8-week program
is used, in acute myeloblastic leukemia - therapy according to the 7 +
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3 protocol. The following drugs are used: Prednisolone, Vincristine,
Rubomycin, Cytosar, Cyclophosphamide, 6-Mercaptopurine, Aspara-
ginase, Etoposide. Concomitant therapy: to improve renal function,
reduce the degree of hyperuricemia - Allopurinol, antiemetic therapy,
hemostatic therapy (transfusion of platelet concentrates), replacement
transfusion of erythrocyte-containing media. With a poor prognostic
index in the remission phase of the disease, allogeneic bone marrow
transplantation is indicated.
4. Medical and labor expertise. Dispensary observation.
Contraindicated types and working conditions: heavy and moder-
ate physical labor, signicant neuropsychic stress, unfavorable me-
teorological conditions, contact with industrial poisons, benzene, ion-
izing radiation.
Disability criteria.
III group of disability is determined in the presence of complete
and stable remission, lasting at least a year after the completion of
the specic therapy program, in connection with the limitations of the
ability to work I Art. And the need to reduce the volume of labor or
transfer to another job,
retraining of a non-contraindicated profession.
II group of disability is determined in the presence of complete
and stable remission, lasting at least a year with the continuation of the
specic therapy program, low rehabilitation potential due to age, the
presence of persistent severe dysfunctions of other organs and systems
as a result complications of the disease or cytostatic therapy, due to
limitations ability to work II-III Art., Movement II Art., Self-service
Art II. and teaching II Art. Shown work in specially created condi-
tions.
I group of disability is determined for the primary referral to
MSEC in primary active stage, even if remission is achieved, last-
ing less than a year and in case of relapse, which is associated with
signicantly pronounced disorders functions of the blood system and
other systems caused by the disease and highly toxic therapy, as well
as a poor prognosis.
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Dispensary supervision is carried out by the hematologist of the
specialized center and the family doctor of the polyclinic. The fre-
quency of examinations by a family doctor in the period of remission
is once every 2 weeks, by a hematologist once every 2 months, and
other specialists according to indications. Considering that the patient
receives maintenance cytostatic therapy almost all the time, blood tests
should be performed at least once every 2 weeks. Biochemical studies
are carried out 1 time in 3 months and if an exacerbation is suspected.
Clinical case No. 2
1. What is the preliminary diagnosis?
Chronic lymphocytic leukemia, relapse, stage A.
2. What additional tests would you recommend to the patient,
and what are the expected results?
¾ Examination of bone marrow in chronic lymphocytic leukemia.
Detection of more than 30% of lymphocytes in the myelogram (if the
aspirate is not diluted with peripheral blood) and lymphoid inltration
of the bone marrow according to trepan biopsy are of diagnostic value.
The nature of bone marrow inltration has prognostic signicance:
nodular and interstitial lesions are more favorable than diuse ones.
¾ Biochemical and immunological studies in chronic
lymphocytic leukemia. In chronic lymphocytic leukemia, there are
no pathognomonic changes in biochemical parameters. At the same
time, an increase in the content of uric acid (with leukocytosis), total
LDH (reects the volume of the tumor mass and is an unfavorable
prognostic sign), as well as hypogammaglobulinemia, correlating
with the frequency of infectious complications, are characteristic.
¾ In the majority of patients, a decrease in the level of
immunoglobulins G, M and A is found. The determination of the
immunophenotype is extremely important for the diagnosis and
dierential diagnosis. Typical immunophenotype in B-cell CLL: CD5
+, CD19 +, CD20 +, CD22 ±, CD79a +, CD23 +, CD43 +, CDllct,
CD10-, cyclin D1-. As a rule, FMC7 and CD79b are negative. When
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